Early Use of Steroid-Sparing Agents in the Inactivation of Moderate-to-Severe Active Thyroid eye Disease

A Step-Down Approach

Zuzana Sipkova; Elizabeth A. Insull; Joel David; Helen E. Turner; Shay Keren; Jonathan H. Norris


Clin Endocrinol. 2018;89(6):834-839. 

In This Article


Thyroid eye disease (TED) is the most common cause of orbital disease in adults and causes significant morbidity in those with Graves' disease.[1] TED is an autoimmune condition characterised by enlargement of orbital adipose tissues and extra-ocular eye muscles. Clinical features are varied and may include a combination of proptosis, periocular soft tissue swelling, pain, impaired extraocular motility, diplopia, and visual impairment. These features often negatively impact on psycho-social well-being.[2]

Management of TED is challenging and the optimal treatment regimen has yet to be determined. Administration of glucocorticosteroids (GC) in the form of pulsed intravenous methylprednisolone (IVMP) is the first-line recommended treatment based on the European Group on Graves' Orbitopathy (EUGOGO) guidelines, for patients with moderate-to-severe active TED.[3,4] This has proved the mainstay of treatment for many departments in the United Kingdom (UK) for the last decade. However, chronic use of GC is associated with several potential significant adverse effects, including: hypertension, infections, gastritis, diabetes, osteoporosis, liver failure and death, and the risk of relapse of active disease following steroid discontinuation.[5,6] Numerous alternative treatments including immuno-suppressive therapies and biologic agents have been proposed; however, the effectiveness of these treatments is still widely debated in literature.[7–10]

The aim of this study was to evaluate the effect on disease activity of steroid sparing agents (SSAs) as first-line therapy in patients with moderate-to-severely active thyroid eye disease (TED).